CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2010 ending 03/31/2010 Date of Report:05/17/2010 Page: 1
Payclass Filters:MED
Eligibility Filter:DEI Only
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 136 321.00 11867.75 36.97
Subtotal (Total Children Is Unduplicated) 136 321.00 11867.75 36.97
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.00 75.00 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.00 75.00 75.00
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 12.50 937.50 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 11.50 862.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 11.50 638.25 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 15.00 1125.00 75.00
Subtotal (Total Children Is Unduplicated) 25 52.50 3713.25 70.73
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 79.00 3950.00 50.00
OCCT-97530-OT SESSION BY LICENSED OT 1 3.00 203.64 67.88
PHY-97110-PT SESSION BY LICENSED PT 1 12.00 814.56 67.88
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.50 373.34 67.88
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.00 52.80 13.20
Subtotal (Total Children Is Unduplicated) 12 103.50 5394.34 52.12
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Total 477.00 20975.34 43.97
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Number of Children (Unduplicated) With at Least One Service 139
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Center 01
Flag Claims Units Chgs Paid
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R 13 7.75 286.75 0.00
U 0 0.00 0.00 0.00
B 123 86.25 3220.00 0.00
P 283 208.00 8206.50 8206.50
D 6 5.25 194.25 0.00
S 43 30.25 1119.25 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
30 75.50 3893.66 0.00
Other 49 64.00 4054.93 0.00
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Total 547 477.00 20975.34 8206.50